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Editor's Comment
June 24, 2020

Cancer, Coverage, and COVID-19

Author Affiliations
  • 1Deputy Editor, JAMA Health Forum
  • 2Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
JAMA Health Forum. 2020;1(6):e200796. doi:10.1001/jamahealthforum.2020.0796

Amid the medical news dominated by coronavirus disease 2019 (COVID-19), the JAMA Network has published a set of articles that boost our understanding of the critical role of insurance coverage in cancer treatment. A recent article in JAMA Pediatrics quantified the extent to which Medicaid expansion leads to increased insurance coverage for children with cancer.1 Recent research comparing Medicaid expansion states with nonexpansion states has demonstrated that insurance coverage improves survival for non–small cell lung cancer, in part because of earlier diagnosis.2,3 Yet, important differences in cancer survival may also exist by insurance status, with Medicaid coverage being the least advantageous for cancer outcomes compared with Medicare and private insurance.4,5

We also know that disparities in early-stage detection of breast cancer are associated with insurance status and especially with lack of insurance.6 Furthermore, we have learned that children of color have worse cancer outcomes, with disparities more pronounced among cancers more amenable to treatment, likely owing to access to care—which is itself driven by insurance status and household financial resources.7

In addition, economists have long taught their students about the job lock that results from an employer-based system in which individuals become “locked” in jobs to maintain their insurance. New estimates published this spring in JAMA Oncology indicate that 1 in 3 adult cancer survivors report that they or their spouse/partner experienced job lock.8 Those with an income between 138% and 400% of the federal poverty level were at increased risk because they were low income yet did not qualify for Medicaid even if their state of residence had expanded Medicaid coverage.

At any other time, this collection of findings might have increased calls for insurance coverage options; however, they have arrived at a moment when attention is focused on the millions who have lost their jobs, with those least able to maintain coverage being the most affected.9,10 The Kaiser Family Foundation estimates that more than 20 million people losing job-based coverage will be eligible for coverage through Medicaid or Marketplace plans, but 6 million are not eligible and are at risk of becoming uninsured. Therefore, people who do have a job may be more locked in it than ever during a recession.

On top of this, there is a growing understanding that COVID-19 will bring with it excess deaths owing to lower cancer screening rates, even in the absence of the economic upheavals that are disrupting insurance coverage. Ned Sharpless, director of the National Cancer Institute, has estimated that there will be an additional 10 000 excess deaths from breast and colorectal cancers alone because of lower screening rates.11 He likened this to a public health crisis within a public health crisis. Given what we now understand with more nuance than ever, rising uninsurance is yet another layer to these crises faced by current and future patients with cancer.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Barnes  JM, Barker  AR, King  AA, Johnson  KJ.  Association of Medicaid expansion with insurance coverage among children with cancer.   JAMA Pediatr. 2020;174(6):581-591. doi:10.1001/jamapediatrics.2020.0052PubMedGoogle ScholarCrossref
Liu  Y, Colditz  GA, Kozower  BD,  et al.  Association of Medicaid expansion under the Patient Protection and Affordable Care Act with non–small cell lung cancer survival.   JAMA Oncol. Published online May 14, 2020. doi:10.1001/jamaoncol.2020.1040PubMedGoogle Scholar
Takvorian  SU, Oganisian  A, Mamtani  R,  et al.  Association of Medicaid expansion under the Affordable Care Act with insurance status, cancer stage, and timely treatment among patients with breast, colon, and lung cancer.   JAMA Netw Open. 2020;3(2):e1921653. doi:10.1001/jamanetworkopen.2019.21653PubMedGoogle Scholar
Pezzi  TA, Schwartz  DL, Pisters  KMW,  et al.  Association of Medicaid insurance with survival among patients with small cell lung cancer.   JAMA Netw Open. 2020;3(4):e203277. doi:10.1001/jamanetworkopen.2020.3277PubMedGoogle Scholar
Unger  JM, Blanke  CD, LeBlanc  M,  et al.  Association of patient demographic characteristics and insurance status with survival in cancer randomized clinical trials with positive findings.   JAMA Netw Open. 2020;3(4):e203842. doi:10.1001/jamanetworkopen.2020.3842PubMedGoogle Scholar
Ko  NY, Hong  S, Winn  RA, Calip  GS.  Association of insurance status and racial disparities with the detection of early-stage breast cancer.   JAMA Oncol. 2020;6(3):385-392. doi:10.1001/jamaoncol.2019.5672PubMedGoogle ScholarCrossref
Delavar  A, Barnes  JM, Wang  X, Johnson  KJ.  Associations between race/ethnicity and US childhood and adolescent cancer survival by treatment amenability.   JAMA Pediatr. 2020;174(5):428-436. doi:10.1001/jamapediatrics.2019.6074PubMedGoogle ScholarCrossref
Kent  EE, de Moor  JS, Zhao  J, Ekwueme  DU, Han  X, Yabroff  KR.  Staying at one’s job to maintain employer-based health insurance among cancer survivors and their spouses/partners.   JAMA Oncol. 2020;6(6):929-932. doi:10.1001/jamaoncol.2020.0742PubMedGoogle ScholarCrossref
Ku  L, Brantley  E.  Widening social and health inequalities during the COVID-19 pandemic.   JAMA Health Forum. 2020;1(6):e200721. doi:10.1001/jamahealthforum.2020.0721Google Scholar
Antos  J, Capretta  J.  Job-based insurance in a COVID-19 world.   JAMA Health Forum. 2020;1(6):e200668. doi:10.1001/jamahealthforum.2020.0668Google Scholar
Sharpless  NE.  COVID-19 and cancer.   Science. 2020;368(6497):1290. https://science.sciencemag.org/content/368/6497/1290. doi:10.1126/science.abd3377PubMedGoogle ScholarCrossref
1 Comment for this article
Insurance Coverage of Cancer Amid COVID-19
Michael McAleer, PhD(Econometrics),Queen's | Asia University, Taiwan
The editor's invaluable and informative analysis of insurance coverage of cancer treatment amid COVID-19 highlights critical medical, social, economic, and financial considerations.

Different countries have varying coverage of cancer treatment, including private health insurance that might be covered personally, as well as by employers, otherwise known as "job lock".

In the USA, the extent of insurance coverage by Medicaid seems to differ by state, which affects cancer survival relative to coverage by Medicare and private health and medical insurance.

The lack of universal health coverage affects the screening and detection of different types of cancer, and the
associated survival rates, according to age, gender, race, employment status, and economic and financial hardship.

As governments have a collective responsibility to provide the best health care facilities and services to all of their citizens, the provable and preventable discrepancies and inequities reflect on the societies in which they exist and continue to multiply.